Back Pain Soap Note


This SOAP note is a detailed recording of the diagnosis and session summary of Mr. Logan Allen, specific to back pain management. It records subjective, objective, assessment, and planning aspects of his medical health and progress. The document is prepared by Juanita L. Riley, a professional from Crystal Clear Communications.





  • Presumably, the patient is likely experiencing chronic back pain.

  • Probable difficulties in accomplishing daily tasks.

  • Presumable history of physical workload.

  • Patient’s physical appearance suggests discomfort and pain, possibly due to back pain.

  • Difficulty with mobility and physical efforts observed.

  • Physical examination reveals reduced flexibility and musculoskeletal deformity.

  • Diagnosis suggests chronic back pain.

  • Potential underlying issues could be disc abnormalities or muscular tension.

  • Patient health and functionality impacted due to the condition.

  • Recommend comprehensive treatment plan, including medication, physical therapy, and possibly surgery.

  • Close monitoring of the patient's pain levels and improvements.

  • Secondary consultation may be recommended to assess the effectiveness of treatment.

Prepared by: Juanita L. Riley, Crystal Clear Communications
Date: January 12th, 2054

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